Notification of Changes for Business Entity
General Information
Business Entity Name:	CBIZ INSURANCE SERVICES, INC
Incorporation / Formation Date:
FEIN:	520807416
Ohio License Number:
NPN:
DBA / Trade Name:
State of Domicile:	MD
County:	ALLEGANY
Business Address
Address 1:	44 BALTIMORE ST.
Address 2:
City:	CUMBERLAND
State:	MD
Zip:	21502
Phone:	301-624-5914
Fax:
Business Web Site Address:
Business Email Address:
Mailing Address
Address 1:	700 W. 47TH ST.
Address 2:	SUITE 1100
City:	KANSAS CITY
State:	MO
Zip:	64112
Indicate the type of change you are seeking
Address Change:	NO
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	NO	New DBA/Trade Name:
Amend DBA/Trade Name:	NO	Old DBA/Trade Name:
Add/Delete Producers, Members, Owners, Partners, Officers and/or Directors:	YES

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date
LINDSAY EINER	CSR	17348269	YES		5/4/2016

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date

Title Business Entities Only
1. Is any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance? (i.e. banking, auto dealer, mortgage company)
2. Has any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance since the filing of the previous CN-65 or the original application?
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement

Submitted By
Submitted By:	DIANE GARVEY
Title:	LICENSING COORDINATOR
Phone Number:	816-945-5263
Email Address:	DGARVEY@CBIZ.COM